The U.S. Supreme Court has upheld Tennessee’s ban on gender-affirming surgery for transgender youth in a ruling that’s likely to reverberate across the country. Most Republican-controlled states already have similar bans. Since President Donald Trump returned to office this year, the federal government has been trying to restrict access.

The justices ruled that Tennessee’s law, which prohibited some medical treatments for transgender youths, did not violate equal protection principles.

The Supreme Court’s Skrmetti ruling spotlighted a split, of sorts, within the court’s Democratic-appointed minority: Justices Elena Kagan, Sonia Sotomayor and Ketanji Brown Jackson.